| Element | Data |
|---|---|
| Patient Name | Juana Mariana Gonzales |
| Mother's Maiden Name | Maria Acosta |
| ID Number | 123456 987633 |
| Date/Time of Birth | 12/23/2009 11:05 |
| Administrative Sex | Female |
| Patient Address 1 | 4345 Standish Way Stamford CT 06903 USA |
| Patient Address 2 | 325 Shorline Drive Stamford CT 06901 |
| Local Number | (203)555-1212 |
| Race1 | Other Race |
| Ethnic Group | Hispanic or Latino |
| Birth Order |
| Element | Data |
|---|---|
| Immunization Registry Status | A |
| Immunization Registry Status Effective Date | 07/01/2012 |
| Publicity Code | Reminder/Recall - any method |
| Publicity Code Effective Date | 07/01/2012 |
| Protection Indicator | |
| Protection Indicator Effective Date |
| Element | Data |
|---|---|
| Name | Joanna Merida Gonzales |
| Relationship | Grandparent |
| Address1 | 4345 Standish Way Stamford CT 06901 |
| Phone Number | (203)555-1212 |
| Element | Data |
|---|---|
| Administered Code | hepatitis B vaccine, pediatric or pediatric/adolescent dosage |
| Date/Time Start of Administration | 11/23/2009 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | Lisa Sirtis |
| Substance Lot Number | 6332FK33 |
| Substance Expiration Date | 12/14/2010 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Shoreline Hospital |
| Entered By | Lisa Sirtis |
| Ordered By | Jane Carter |
| Element | Data |
|---|---|
| Administered Code | hepatitis B vaccine, unspecified formulation |
| Date/Time Start of Administration | 01/15/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical Immunization |
| Administering Provider | Sandra Molina |
| Substance Lot Number | 6352FK1 |
| Substance Expiration Date | 10/01/2010 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| Administered Code | hepatitis B vaccine, pediatric or pediatric/adolescent dosage |
| Date/Time Start of Administration | 10/30/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6352FK24 |
| Substance Expiration Date | 08/31/2012 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified |
| Date/Time Start of Administration | 01/22/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D409QS2341 |
| Substance Expiration Date | 11/30/2011 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis |
| Date/Time Start of Administration | 03/23/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D409QS2433 |
| Substance Expiration Date | 09/04/2011 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis |
| Date/Time Start of Administration | 05/22/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D409QS3255 |
| Substance Expiration Date | 12/01/2010 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Reaction | fever of >40.5C (105F) within 48 hours of dose |
| Element | Data |
|---|---|
| Administered Code | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis |
| Date/Time Start of Administration | 02/21/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D409QS249 |
| Substance Expiration Date | 03/01/2011 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis |
| Date/Time Start of Administration | 08/31/2014 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from other provider |
| Administering Provider | Linda Casera |
| Substance Lot Number | D643QS8243 |
| Substance Expiration Date | 09/01/2014 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | J Rodriguez |
| Element | Data |
|---|---|
| Administered Code | Haemophilus influenzae type b vaccine, PRP-OMP conjugate |
| Date/Time Start of Administration | 01/22/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 7M54K9245 |
| Substance Expiration Date | 03/24/2010 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | Haemophilus influenzae type b vaccine, PRP-OMP conjugate |
| Date/Time Start of Administration | 03/23/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 7M55K3342 |
| Substance Expiration Date | 10/30/2010 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | Haemophilus influenzae type b vaccine, PRP-OMP conjugate |
| Date/Time Start of Administration | 05/22/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 7M75K4566 |
| Substance Expiration Date | 05/23/2010 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | Haemophilus influenzae type b vaccine, PRP-OMP conjugate |
| Date/Time Start of Administration | 02/21/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 7M53K5534 |
| Substance Expiration Date | 02/22/2011 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | poliovirus vaccine, inactivated |
| Date/Time Start of Administration | 01/22/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D333PV2431 |
| Substance Expiration Date | 10/04/2010 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | SC |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | poliovirus vaccine, inactivated |
| Date/Time Start of Administration | 03/23/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D333PV4344 |
| Substance Expiration Date | 03/23/2010 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | SC |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | poliovirus vaccine, inactivated |
| Date/Time Start of Administration | 02/21/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from other provider |
| Administering Provider | Linda Casera |
| Substance Lot Number | D335PV9644 |
| Substance Expiration Date | 02/22/2011 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | SC |
| Administration Site | Left Deltoid |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | J Rodriguez |
| Element | Data |
|---|---|
| Administered Code | poliovirus vaccine, inactivated |
| Date/Time Start of Administration | 05/19/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | Parental decision |
| Completion Status | RE |
| Action Code | Add |
| Route | |
| Administration Site | |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| Administered Code | pneumococcal conjugate vaccine, 13 valent |
| Date/Time Start of Administration | 01/21/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | P243V3281 |
| Substance Expiration Date | 01/30/2010 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | pneumococcal conjugate vaccine, 13 valent |
| Date/Time Start of Administration | 03/23/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | P343V8321 |
| Substance Expiration Date | 03/30/2010 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | SC |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | pneumococcal conjugate vaccine, 13 valent |
| Date/Time Start of Administration | 05/22/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | P853V2164 |
| Substance Expiration Date | 08/30/2010 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | pneumococcal conjugate vaccine, 13 valent |
| Date/Time Start of Administration | 02/21/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | P853V58532 |
| Substance Expiration Date | 04/18/2011 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | rotavirus, live, monovalent vaccine |
| Date/Time Start of Administration | 01/22/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6359RV533 |
| Substance Expiration Date | 02/15/2010 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | rotavirus, live, monovalent vaccine |
| Date/Time Start of Administration | 03/23/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6359RV932 |
| Substance Expiration Date | 05/10/2010 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | Influenza, injectable,quadrivalent, preservative free, pediatric |
| Date/Time Start of Administration | 09/25/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D8043IN8734 |
| Substance Expiration Date | 03/12/2011 |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | Influenza, injectable,quadrivalent, preservative free, pediatric |
| Date/Time Start of Administration | 10/27/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D8043IN8734 |
| Substance Expiration Date | 03/12/2011 |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | Influenza, injectable,quadrivalent, preservative free, pediatric |
| Date/Time Start of Administration | 10/02/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D9334IN9333 |
| Substance Expiration Date | 05/22/2012 |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | Influenza, injectable,quadrivalent, preservative free, pediatric |
| Date/Time Start of Administration | 10/15/2013 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from parents written record |
| Administering Provider | Gina Ricci |
| Substance Lot Number | 8L4B3423 |
| Substance Expiration Date | 07/01/2014 |
| Substance Manufacturer Name | MedImmune, LLC |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | Nasal |
| Administration Site | Bilateral Nares |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Gina Ricci |
| Element | Data |
|---|---|
| Administered Code | influenza, live, intranasal, quadrivalent |
| Date/Time Start of Administration | 07/15/2015 |
| Administered Amount | 0.2 |
| Administered Units | |
| Administration Notes | New immunization record |
| Administering Provider | Sandra Molina |
| Substance Lot Number | 8L4B3521 |
| Substance Expiration Date | 08/15/2015 |
| Substance Manufacturer Name | MedImmune,LLC |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | Nasal |
| Administration Site | Bilateral Nares |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| VIS Publication Date | 08/19/2014 |
| VIS Presentation Date | 07/15/2015 |
| vaccine fund pgm elig cat | Not VFC elig |
| Element | Data |
|---|---|
| Administered Code | influenza, live, intranasal, quadrivalent |
| Date/Time Start of Administration | 11/04/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D9553IN2243 |
| Substance Expiration Date | 04/30/2012 |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule |
| Date/Time Start of Administration | 11/23/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6359RT33 |
| Substance Expiration Date | 01/24/2012 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule |
| Date/Time Start of Administration | 05/23/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6359RT48 |
| Substance Expiration Date | 09/11/2012 |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | F Smith |
| Element | Data |
|---|---|
| Administered Code | measles, mumps, rubella, and varicella virus vaccine |
| Date/Time Start of Administration | 10/23/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | historical |
| Administering Provider | J Martinez |
| Substance Lot Number | 7W27V7491 |
| Substance Expiration Date | 12/15/2010 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | Subcutaneous |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | F Smith |
| Element | Data |
|---|---|
| Administered Code | measles, mumps, rubella, and varicella virus vaccine |
| Date/Time Start of Administration | 11/22/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 7W87V3452 |
| Substance Expiration Date | 04/13/2013 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | Subcutaneous |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | F Smith |
| Element | Data |
|---|---|
| Administered Code | measles, mumps, rubella, and varicella virus vaccine |
| Date/Time Start of Administration | 07/15/2015 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | New immunization record |
| Administering Provider | Sandra Molina |
| Substance Lot Number | 7W87V3687 |
| Substance Expiration Date | 07/15/2015 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | Subcutaneous |
| Administration Site | Left Deltoid |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| VIS Publication Date | 05/21/2010 |
| VIS Presentation Date | 07/15/2015 |
| vaccine fund pgm elig cat | Not VFC elig |
| Description |
|---|
Following the vaccine administration, the patient's mother reports that the patient that evening had persistent, inconsolable crying lasting > 3 hours. |
| Comments |
|---|
No Comments |
| PreCondition |
|---|
The vaccinations for the visit have been administered. |
| PostCondition |
|---|
The adverse reaction to the MMRV of persistent, inconsolable crying lasting > 3 hours within 48 hours of dose is recorded in the EMR. |
| Test Objectives |
|---|
Identify Adverse Event: The EHR or other clinical software system enables capture of structured data regarding adverse events. |
| Evaluation Criteria |
|---|
Verify that vendor can record the adverse reaction of persistent, inconsolable crying lasting > 3 hours within 48 hours of dose correctly and without omission |
| Notes to Testers |
|---|
No Note |
| Description |
|---|
The adverse reaction to the MMRV of persistent, inconsolable crying lasting > 3 hours within 48 hours of dose is reported to the Immunization Registry using a Z22/VXU message. |
| Comments |
|---|
No Comments |
| PreCondition |
|---|
An adverse reaction to the MMRV of persistent, inconsolable crying lasting > 3 hours within 48 hours of dose is recorded in the EMR. |
| PostCondition |
|---|
The adverse reaction has been transmitted to the IIS. |
| Test Objectives |
|---|
Transmit Standard Patient Immunization History Report: The EHR or other clinical software system directly or indirectly through an intermediary creates and transmits a report of a patient's immunization history to public health immunization registries. |
| Evaluation Criteria |
|---|
The VXU/Z22 message passes validation using the NIST Immunization VXU Validation Tool (Z22) (context-free). The content of the message correctly reflects the test data (context-based) in accordance with the Test Data Specification and the Message Content. |
| Notes to Testers |
|---|
No Note |
| Element | Data |
|---|---|
| Patient Name | Juana Mariana Gonzales |
| Mother's Maiden Name | Maria Acosta |
| ID Number | 123456 987633 |
| Date/Time of Birth | 12/23/2009 11:05 |
| Administrative Sex | Female |
| Patient Address 1 | 4345 Standish Way Stamford CT 06903 USA |
| Patient Address 2 | 325 Shorline Drive Stamford CT 06901 |
| Local Number | (203)555-1212 |
| Race1 | Other Race |
| Ethnic Group | Hispanic or Latino |
| Birth Order |
| Element | Data |
|---|---|
| Immunization Registry Status | A |
| Immunization Registry Status Effective Date | 07/01/2012 |
| Publicity Code | Reminder/Recall - any method |
| Publicity Code Effective Date | 07/01/2012 |
| Protection Indicator | |
| Protection Indicator Effective Date |
| Element | Data |
|---|---|
| Name | Joanna Merida Gonzales |
| Relationship | Grandparent |
| Address1 | 4345 Standish Way Stamford CT 06901 |
| Phone Number | (203)555-1212 |
| Element | Data |
|---|---|
| Administered Code | hepatitis B vaccine, pediatric or pediatric/adolescent dosage |
| Date/Time Start of Administration | 11/23/2009 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | Lisa Sirtis |
| Substance Lot Number | 6332FK33 |
| Substance Expiration Date | 12/14/2010 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Shoreline Hospital |
| Entered By | Lisa Sirtis |
| Ordered By | Jane Carter |
| Element | Data |
|---|---|
| Administered Code | hepatitis B vaccine, unspecified formulation |
| Date/Time Start of Administration | 01/15/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical Immunization |
| Administering Provider | Sandra Molina |
| Substance Lot Number | 6352FK1 |
| Substance Expiration Date | 10/01/2010 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| Administered Code | hepatitis B vaccine, pediatric or pediatric/adolescent dosage |
| Date/Time Start of Administration | 10/30/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6352FK24 |
| Substance Expiration Date | 08/31/2012 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified |
| Date/Time Start of Administration | 01/22/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D409QS2341 |
| Substance Expiration Date | 11/30/2011 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis |
| Date/Time Start of Administration | 03/23/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D409QS2433 |
| Substance Expiration Date | 09/04/2011 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis |
| Date/Time Start of Administration | 05/22/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D409QS3255 |
| Substance Expiration Date | 12/01/2010 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Reaction | fever of >40.5C (105F) within 48 hours of dose |
| Element | Data |
|---|---|
| Administered Code | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis |
| Date/Time Start of Administration | 02/21/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D409QS249 |
| Substance Expiration Date | 03/01/2011 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis |
| Date/Time Start of Administration | 08/31/2014 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from other provider |
| Administering Provider | Linda Casera |
| Substance Lot Number | D643QS8243 |
| Substance Expiration Date | 09/01/2014 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | J Rodriguez |
| Element | Data |
|---|---|
| Administered Code | Haemophilus influenzae type b vaccine, PRP-OMP conjugate |
| Date/Time Start of Administration | 01/22/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 7M54K9245 |
| Substance Expiration Date | 03/24/2010 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | Haemophilus influenzae type b vaccine, PRP-OMP conjugate |
| Date/Time Start of Administration | 03/23/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 7M55K3342 |
| Substance Expiration Date | 10/30/2010 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | Haemophilus influenzae type b vaccine, PRP-OMP conjugate |
| Date/Time Start of Administration | 05/22/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 7M75K4566 |
| Substance Expiration Date | 05/23/2010 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | Haemophilus influenzae type b vaccine, PRP-OMP conjugate |
| Date/Time Start of Administration | 02/21/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 7M53K5534 |
| Substance Expiration Date | 02/22/2011 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | poliovirus vaccine, inactivated |
| Date/Time Start of Administration | 01/22/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D333PV2431 |
| Substance Expiration Date | 10/04/2010 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | SC |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | poliovirus vaccine, inactivated |
| Date/Time Start of Administration | 03/23/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D333PV4344 |
| Substance Expiration Date | 03/23/2010 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | SC |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | poliovirus vaccine, inactivated |
| Date/Time Start of Administration | 02/21/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from other provider |
| Administering Provider | Linda Casera |
| Substance Lot Number | D335PV9644 |
| Substance Expiration Date | 02/22/2011 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | SC |
| Administration Site | Left Deltoid |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | J Rodriguez |
| Element | Data |
|---|---|
| Administered Code | poliovirus vaccine, inactivated |
| Date/Time Start of Administration | 05/19/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | Parental decision |
| Completion Status | RE |
| Action Code | Add |
| Route | |
| Administration Site | |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| Administered Code | pneumococcal conjugate vaccine, 13 valent |
| Date/Time Start of Administration | 01/21/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | P243V3281 |
| Substance Expiration Date | 01/30/2010 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | pneumococcal conjugate vaccine, 13 valent |
| Date/Time Start of Administration | 03/23/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | P343V8321 |
| Substance Expiration Date | 03/30/2010 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | SC |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | pneumococcal conjugate vaccine, 13 valent |
| Date/Time Start of Administration | 05/22/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | P853V2164 |
| Substance Expiration Date | 08/30/2010 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | pneumococcal conjugate vaccine, 13 valent |
| Date/Time Start of Administration | 02/21/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | P853V58532 |
| Substance Expiration Date | 04/18/2011 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | rotavirus, live, monovalent vaccine |
| Date/Time Start of Administration | 01/22/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6359RV533 |
| Substance Expiration Date | 02/15/2010 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | rotavirus, live, monovalent vaccine |
| Date/Time Start of Administration | 03/23/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6359RV932 |
| Substance Expiration Date | 05/10/2010 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | Influenza, injectable,quadrivalent, preservative free, pediatric |
| Date/Time Start of Administration | 09/25/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D8043IN8734 |
| Substance Expiration Date | 03/12/2011 |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | Influenza, injectable,quadrivalent, preservative free, pediatric |
| Date/Time Start of Administration | 10/27/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D8043IN8734 |
| Substance Expiration Date | 03/12/2011 |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | Influenza, injectable,quadrivalent, preservative free, pediatric |
| Date/Time Start of Administration | 10/02/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D9334IN9333 |
| Substance Expiration Date | 05/22/2012 |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | Influenza, injectable,quadrivalent, preservative free, pediatric |
| Date/Time Start of Administration | 10/15/2013 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from parents written record |
| Administering Provider | Gina Ricci |
| Substance Lot Number | 8L4B3423 |
| Substance Expiration Date | 07/01/2014 |
| Substance Manufacturer Name | MedImmune, LLC |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | Nasal |
| Administration Site | Bilateral Nares |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Gina Ricci |
| Element | Data |
|---|---|
| Administered Code | influenza, live, intranasal, quadrivalent |
| Date/Time Start of Administration | 07/15/2015 |
| Administered Amount | 0.2 |
| Administered Units | |
| Administration Notes | New immunization record |
| Administering Provider | Sandra Molina |
| Substance Lot Number | 8L4B3521 |
| Substance Expiration Date | 08/15/2015 |
| Substance Manufacturer Name | MedImmune,LLC |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | Nasal |
| Administration Site | Bilateral Nares |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| VIS Publication Date | 08/19/2014 |
| VIS Presentation Date | 07/15/2015 |
| vaccine fund pgm elig cat | Not VFC elig |
| Element | Data |
|---|---|
| Administered Code | influenza, live, intranasal, quadrivalent |
| Date/Time Start of Administration | 11/04/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | D9553IN2243 |
| Substance Expiration Date | 04/30/2012 |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule |
| Date/Time Start of Administration | 11/23/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6359RT33 |
| Substance Expiration Date | 01/24/2012 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | Carlos Herrera |
| Element | Data |
|---|---|
| Administered Code | hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule |
| Date/Time Start of Administration | 05/23/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 6359RT48 |
| Substance Expiration Date | 09/11/2012 |
| Substance Manufacturer Name | Sanofi PasteurGlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | F Smith |
| Element | Data |
|---|---|
| Administered Code | measles, mumps, rubella, and varicella virus vaccine |
| Date/Time Start of Administration | 10/23/2010 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | historical |
| Administering Provider | J Martinez |
| Substance Lot Number | 7W27V7491 |
| Substance Expiration Date | 12/15/2010 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | Subcutaneous |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | F Smith |
| Element | Data |
|---|---|
| Administered Code | measles, mumps, rubella, and varicella virus vaccine |
| Date/Time Start of Administration | 11/22/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | J Martinez |
| Substance Lot Number | 7W87V3452 |
| Substance Expiration Date | 04/13/2013 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | Subcutaneous |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J Martinez |
| Ordered By | F Smith |
| Element | Data |
|---|---|
| Administered Code | measles, mumps, rubella, and varicella virus vaccine |
| Date/Time Start of Administration | 07/15/2015 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | New immunization record |
| Administering Provider | Sandra Molina |
| Substance Lot Number | 7W87V3687 |
| Substance Expiration Date | 07/15/2015 |
| Substance Manufacturer Name | Merck Sharp \T\ Dohme Corp |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | Subcutaneous |
| Administration Site | Left Deltoid |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| VIS Publication Date | 05/21/2010 |
| VIS Presentation Date | 07/15/2015 |
| vaccine fund pgm elig cat | Not VFC elig |
| vaccine fund pgm elig cat | Not VFC elig |
| Reaction | persistent, inconsolable crying lasting > 3 hours within 48 hours of dose |
| Description |
|---|
| No Description |
| Comments |
|---|
| No Comments |
| PreCondition |
|---|
| No PreCondition |
| PostCondition |
|---|
| No PostCondition |
| Test Objectives |
|---|
| No Test Objectives |
| Evaluation Criteria |
|---|
| No evaluation criteria |
| Notes to Testers |
|---|
| No Note |
| Description |
|---|
Following the vaccinations given during the visit, the EMR transmits an Immunization report to the Immunization Registry using the VXU/Z22. The Vaccination report includes all newly administered vaccines. The report MAY send the immunizations that the EMR imported from the IIS. |
| Comments |
|---|
The Report must include all newly administered vaccines in any order. The report may include the information imported from the IIS. |
| PreCondition |
|---|
The vaccines for the visit have been administered. |
| PostCondition |
|---|
The Immunization Report has been transmitted to the IIS using a valid Z22 VXU in accordance with the test data correctly and without omission. |
| Test Objectives |
|---|
Transmit Standard Patient Immunization History Report: The EHR or other clinical software system directly or indirectly through an intermediary creates and transmits a report of a patient's immunization history to public health immunization registries. |
| Evaluation Criteria |
|---|
The VXU/Z22 message passes validation using the NIST Immunization VXU Validation Tool (Z22) (context-free). The content of the message correctly reflects the test data (context-based) in accordance with the Test Data Specification and the Message Content. |
| Notes to Testers |
|---|
No Note |
| Element | Data |
|---|---|
| Patient Name | Juan Marcel Gonzales |
| Mother's Maiden Name | Anita Morales |
| ID Number | 123456 987633 |
| Date/Time of Birth | 11/23/2011 11:00 |
| Administrative Sex | Male |
| Patient Address 1 | 4623 Standish Way Stamford CT 06903 USA |
| Local Number | (203)555-1213 |
| Race1 | Other Race |
| Ethnic Group | Hispanic or Latino |
| Birth Order |
| Element | Data |
|---|---|
| Immunization Registry Status | A |
| Immunization Registry Status Effective Date | 07/01/2012 |
| Publicity Code | Reminder/Recall - any method |
| Publicity Code Effective Date | 07/01/2012 |
| Protection Indicator | |
| Protection Indicator Effective Date |
| Element | Data |
|---|---|
| Name | Manuel Marcel Gonzales |
| Relationship | Father |
| Address1 | 4623 Standish Way Stamford CT 06903 |
| Phone Number | (203)555-1213 |
| Element | Data |
|---|---|
| Administered Code | Hepatitis B |
| Date/Time Start of Administration | 11/23/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | 6332FK34 |
| Substance Expiration Date | 12/14/2011 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Shoreline Hospital |
| Entered By | Lisa Sirtis |
| Ordered By | Jane Carter |
| Element | Data |
|---|---|
| Administered Code | Hepatitis B |
| Date/Time Start of Administration | 12/23/2011 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | 6352FK2 |
| Substance Expiration Date | 10/01/2011 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Code | Hepatitis B |
| Date/Time Start of Administration | 07/15/2015 |
| Administered Amount | 0.5 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | Sandra Molina |
| Substance Lot Number | 6332FK26 |
| Substance Expiration Date | 08/25/2015 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| VIS Publication Date | 02/02/2012 |
| VIS Presentation Date | 07/15/2015 |
| vaccine fund pgm elig cat | Not VFC elig |
| Element | Data |
|---|---|
| Administered Code | DTaP |
| Date/Time Start of Administration | 01/22/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | D409QS2342 |
| Substance Expiration Date | 11/30/2012 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Code | DTaP |
| Date/Time Start of Administration | 03/22/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | D409QS2434 |
| Substance Expiration Date | 09/04/2012 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Code | DTaP |
| Date/Time Start of Administration | 05/21/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | D409QS250 |
| Substance Expiration Date | 01/03/2014 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Code | DTaP |
| Date/Time Start of Administration | 02/20/2013 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | D409QS250 |
| Substance Expiration Date | 01/03/2014 |
| Substance Manufacturer Name | Sanofi Pasteur Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Code | Hib |
| Date/Time Start of Administration | 01/22/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | 7M54K9255 |
| Substance Expiration Date | 03/24/2012 |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp. |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Code | Hib |
| Date/Time Start of Administration | 03/22/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | 7M55K3343 |
| Substance Expiration Date | 10/30/2012 |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp. |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Code | Hib |
| Date/Time Start of Administration | 05/12/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | 7M75K4577 |
| Substance Expiration Date | 05/23/2012 |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp. |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Code | Hib |
| Date/Time Start of Administration | 02/22/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | 7M53K5535 |
| Substance Expiration Date | 02/22/2012 |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp. |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Code | Polio (IPV) |
| Date/Time Start of Administration | 01/22/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | D333PV2444 |
| Substance Expiration Date | 04/10/2012 |
| Substance Manufacturer Name | MSanofi Pasteur Inc. |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | SC |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Code | Polio (IPV) |
| Date/Time Start of Administration | 03/22/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | D333PV4343 |
| Substance Expiration Date | 03/23/2012 |
| Substance Manufacturer Name | MSanofi Pasteur Inc. |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | SC |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Code | Polio (IPV) |
| Date/Time Start of Administration | 05/21/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | D333PV4343 |
| Substance Expiration Date | 03/23/2012 |
| Substance Manufacturer Name | MSanofi Pasteur Inc. |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | SC |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Code | Pneumococcal conjugate (PCV13) |
| Date/Time Start of Administration | 01/22/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | P243V3321 |
| Substance Expiration Date | 01/30/2012 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Code | Pneumococcal conjugate (PCV13) |
| Date/Time Start of Administration | 03/22/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | P343V8445 |
| Substance Expiration Date | 03/30/2012 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Code | Pneumococcal conjugate (PCV13) |
| Date/Time Start of Administration | 05/21/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | P853V2175 |
| Substance Expiration Date | 08/30/2012 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Code | Pneumococcal conjugate (PCV13) |
| Date/Time Start of Administration | 11/22/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | P853V58544 |
| Substance Expiration Date | 01/18/2013 |
| Substance Manufacturer Name | Pfizer, Inc |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Code | Rotavirus |
| Date/Time Start of Administration | 11/22/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | 6359RV543 |
| Substance Expiration Date | 02/15/2012 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Code | Rotavirus |
| Date/Time Start of Administration | 03/22/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | 6359RV933 |
| Substance Expiration Date | 05/10/2012 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Thigh Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Code | Influenza |
| Date/Time Start of Administration | 09/22/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | D8043IN8738 |
| Substance Expiration Date | 03/12/2013 |
| Substance Manufacturer Name | Sanofi Pasteur |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Code | Influenza |
| Date/Time Start of Administration | 10/22/2012 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | D8043IN8798 |
| Substance Expiration Date | 03/12/2013 |
| Substance Manufacturer Name | Sanofi Pasteur |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Code | Influenza |
| Date/Time Start of Administration | 10/30/2013 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | D9334IN9433 |
| Substance Expiration Date | 05/22/2014 |
| Substance Manufacturer Name | Sanofi Pasteur |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Code | Influenza |
| Date/Time Start of Administration | 07/15/2015 |
| Administered Amount | 0.25 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | Sandra Molina |
| Substance Lot Number | D8043IN8855 |
| Substance Expiration Date | 08/28/2015 |
| Substance Manufacturer Name | Sanofi Pasteur |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| VIS Publication Date | 08/19/2014 |
| VIS Presentation Date | 07/15/2015 |
| vaccine fund pgm elig cat | Not VFC elig |
| Element | Data |
|---|---|
| Administered Code | Hepatitis A |
| Date/Time Start of Administration | 05/21/2013 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | 6359RT35 |
| Substance Expiration Date | 01/04/2014 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Right Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Code | Hepatitis A |
| Date/Time Start of Administration | 12/01/2013 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | 6359RT47 |
| Substance Expiration Date | 09/11/2013 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Deltoid |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Element | Data |
|---|---|
| Administered Code | MMR and Varicella |
| Date/Time Start of Administration | 01/12/2013 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | J. Martinez |
| Substance Lot Number | 7W27V7632 |
| Substance Expiration Date | 12/15/2016 |
| Substance Manufacturer Name | Merck Sharp and Dohme Corp. |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | SC |
| Administration Site | Left Thigh |
| Entering Organization | Oceanview Pediatrics |
| Entered By | J. Martinez |
| Ordered By | J. Rodriguez |
| Description |
|---|
| No Description |
| Comments |
|---|
| No Comments |
| PreCondition |
|---|
| No PreCondition |
| PostCondition |
|---|
| No PostCondition |
| Test Objectives |
|---|
| No Test Objectives |
| Evaluation Criteria |
|---|
| No evaluation criteria |
| Notes to Testers |
|---|
| No Note |
| Description |
|---|
Following the visit, the EMR transmits an Immunization report to the Immunization Registry using the VXU/Z22. The Vaccination report includes the vaccine deferrals. The report MAY send the immunizations that the EMR imported from the IIS. |
| Comments |
|---|
The Report must include all vaccine deferrals recorded in the EMR in any order. The report may include the information imported from the IIS |
| PreCondition |
|---|
The vaccines for the visit have been administered. |
| PostCondition |
|---|
The Immunization Report has been transmitted to the IIS using a valid Z22 VXU in accordance with the test data correctly and without omission. |
| Test Objectives |
|---|
Transmit Standard Patient Immunization History Report: The EHR or other clinical software system directly or indirectly through an intermediary creates and transmits a report of a patient's immunization history to public health immunization registries. |
| Evaluation Criteria |
|---|
The VXU/Z22 message passes validation using the NIST Immunization VXU Validation Tool (Z22) (context-free). The content of the message correctly reflects the test data (context-based) in accordance with the Test Data Specification and the Message Content. The message must contain all deferrals recorded in the EMR. Current Date is expected for the Non-Administration date and deferral date. |
| Notes to Testers |
|---|
No Note |
| Element | Data |
|---|---|
| Patient Name | Mariela Gonzales Morales |
| Mother's Maiden Name | Joanna Gonzales |
| ID Number | 123456 987633 |
| Date/Time of Birth | 03/30/2015 11:15 |
| Administrative Sex | Female |
| Patient Address 1 | 3321 Standish Way Stamford CT 06903 USA |
| Patient Address 2 | 325 Shorline Drive Stamford CT 06901 |
| Local Number | (203)555-1214 |
| Race1 | Other Race |
| Ethnic Group | Hispanic or Latino |
| Birth Order |
| Element | Data |
|---|---|
| Immunization Registry Status | A |
| Immunization Registry Status Effective Date | 07/01/2012 |
| Publicity Code | Reminder/Recall - any method |
| Publicity Code Effective Date | 07/01/2012 |
| Protection Indicator | |
| Protection Indicator Effective Date |
| Element | Data |
|---|---|
| Name | Joanna Gonzales Morales |
| Relationship | Mother |
| Address1 | 4623 Standish Way Stamford CT 06903 |
| Phone Number | (203)555-1213 |
| Element | Data |
|---|---|
| Administered Code | hepatitis B vaccine, pediatric or pediatric/adolescent dosage |
| Date/Time Start of Administration | 11/23/2009 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | Historical information - from public agency |
| Administering Provider | Lisa Sirtis |
| Substance Lot Number | 6332FK33 |
| Substance Expiration Date | 12/14/2010 |
| Substance Manufacturer Name | GlaxoSmithKline Biologicals SA |
| Substance/Treatment Refusal Reason | |
| Completion Status | CP |
| Action Code | Add |
| Route | IM |
| Administration Site | Left Thigh |
| Entering Organization | Shoreline Hospital |
| Entered By | Lisa Sirtis |
| Ordered By | Jane Carter |
| Element | Data |
|---|---|
| Administered Code | hepatitis B vaccine, unspecified formulation |
| Date/Time Start of Administration | 07/15/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | |
| Completion Status | NA |
| Action Code | Add |
| Route | |
| Administration Site | |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| Vaccination contraindication | current fever with moderate-to-severe illness |
| Vaccination contraindication/precaution effective date | 07/15/2015 |
| Vaccination temporary contraindication/precaution expiration date | 08/15/2015 |
| Element | Data |
|---|---|
| Administered Code | DTaP, unspecified formulation |
| Date/Time Start of Administration | 07/15/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | |
| Completion Status | NA |
| Action Code | Add |
| Route | |
| Administration Site | |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| Vaccination contraindication | current fever with moderate-to-severe illness |
| Vaccination contraindication/precaution effective date | 07/15/2015 |
| Vaccination temporary contraindication/precaution expiration date | 08/15/2015 |
| Element | Data |
|---|---|
| Administered Code | Hib |
| Date/Time Start of Administration | 07/15/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | |
| Completion Status | NA |
| Action Code | Add |
| Route | |
| Administration Site | |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| Vaccination contraindication | current fever with moderate-to-severe illness |
| Vaccination contraindication/precaution effective date | 07/15/2015 |
| Vaccination temporary contraindication/precaution expiration date | 08/15/2015 |
| Element | Data |
|---|---|
| Administered Code | Pneumococcal Conjugate, unspecified formulation |
| Date/Time Start of Administration | 07/15/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | |
| Completion Status | NA |
| Action Code | Add |
| Route | |
| Administration Site | |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| Vaccination contraindication | current fever with moderate-to-severe illness |
| Vaccination contraindication/precaution effective date | 07/15/2015 |
| Vaccination temporary contraindication/precaution expiration date | 08/15/2015 |
| Element | Data |
|---|---|
| Administered Code | rotavirus, unspecified formulation |
| Date/Time Start of Administration | 07/15/2015 |
| Administered Amount | 999 |
| Administered Units | |
| Administration Notes | |
| Administering Provider | |
| Substance Lot Number | |
| Substance Expiration Date | |
| Substance Manufacturer Name | |
| Substance/Treatment Refusal Reason | |
| Completion Status | NA |
| Action Code | Add |
| Route | |
| Administration Site | |
| Entering Organization | Shoreline Pediatrics |
| Entered By | Sandra Molina |
| Ordered By | Frank Smith |
| Element | Data |
|---|---|
| Vaccination contraindication | current fever with moderate-to-severe illness |
| Vaccination contraindication/precaution effective date | 07/15/2015 |
| Vaccination temporary contraindication/precaution expiration date | 08/15/2015 |
| Description |
|---|
| Following the vaccination visit, the provider uses the EMR to produce an immunization report for the patient including all history (the report can be provided in various formats - e.g., print, send to patient portal, etc.) |
| Comments |
|---|
| No Comments |
| PreCondition |
|---|
| Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR. New vaccinations have been administered. |
| PostCondition |
|---|
| The patient/parent has been provided a patient immunization history report. |
| Test Objectives |
|---|
| Produce Standard Patient Immunization History Report: The EHR or other clinical software system produces a report of a patient's immunization history that is appropriate for various entities, such as schools and day-care centers. |
| Evaluation Criteria |
|---|
| No evaluation criteria |
| Notes to Testers |
|---|
| No Note |
| Description |
|---|
|
Following the vaccination visit, the provider uses the EMR to produce an immunization report for the patient including all history (the report can be provided in various formats - e.g., print, send to patient portal, etc.) |
| Comments |
|---|
No Comments |
| PreCondition |
|---|
|
Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR. New vaccinations have been administered. |
| PostCondition |
|---|
|
The patient/parent has been provided a patient immunization history report. |
| Test Objectives |
|---|
|
Produce Standard Patient Immunization History Report: The EHR or other clinical software system produces a report of a patient's immunization history that is appropriate for various entities, such as schools and day-care centers. |
| Evaluation Criteria |
|---|
The following patient demographics are displayed: Patient Identifier Number: Vendor Assigned
Patient Identifier Type Code: Vendor Assigned
Patient Name: Juana Mariana Gonzales
Date/Time of Birth: 12/23/2009 11:05am
Sex: Female
Patient Address: 4345 Standish Way, Stamford, CT, 06903
Multiple Birth: N
Birth Order: NA
The following Vaccination History is displayed:
Vaccine Group: Hep B Peds NOS
Administered: hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08)
ENGERIX-B (NDC 58160-0820-11)"
Date Administered: 12/23/2009
Additional Observations: None
Dose #: 1
Doses in Series: 3
Valid Dose: Y
Ordering Provider: Jane Carter
Entered By: Lisa Sirtis
Entering Organization: Shoreline Hospital
Administered Amt: .05 mL
Administering Provider: Jane Carter
Administered at Location: 325 Shorline Drive,
Stamford Connecticut 06901
Lot#: 6332FK33
Exp Date: 12/14/2010
Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Thigh (HL7 LT)
Vaccine Group: Hep B Peds NOS
Administered: hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08)
ENGERIX-B (NDC 58160-0820-11)"
Date Administered: 1/15/2010
Additional Observations: None
Dose #: 2
Doses in Series: 3
Valid Dose: Y
Ordering Provider: Frank Smith
Entered By: Sandra Molina
Entering Organization: Shoreline Pediatrics
Administered Amt: .05 mL
Administering Provider: Sandra Molina
Administered at Location: 400 Shorline Drive,
Stamford Connecticut 06901
Lot#: 6352FK1
Exp Date: 10/1/2010
Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Right Thigh (HL7 RT)
Vaccine Group: Hep B Peds NOS
Administered: hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08)
ENGERIX-B (NDC 58160-0820-11)"
Date Administered: 10/30/2010
Additional Observations: None
Dose #: 3
Doses in Series: 3
Valid Dose: Y
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: Sandra Molina
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: 6352FK24
Exp Date: 8/31/2012
Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Thigh (HL7 LT)
Vaccine Group: diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
Administered: diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106)
DAPTACEL (NDC 49281-0286-01)"
Date Administered: 1/22/2010
Additional Observations: None
Dose #: 1
Doses in Series: 5
Valid Dose: Y
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: D409QS2341
Exp Date: 11/30/2011
Manufacturer: Sanofi Pasteur Inc (MVX PMC)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Thigh (HL7 LT)
Vaccine Group: diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
Administered: diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106)
DAPTACEL (NDC 49281-0286-01)
Date Administered: 3/23/2010
Additional Observations: 31044-1 Reaction, VXC12^fever of >40.5C (105F) within 48 hours of dose
Dose #: 2
Doses in Series: 5
Valid Dose: Y
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: D409QS2433
Exp Date: 9/4/2011
Manufacturer: Sanofi Pasteur Inc (MVX PMC)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Right Thigh (HL7 RT)
Vaccine Group: diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
Administered: diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106)
DAPTACEL (NDC 49281-0286-01)"
Date Administered: 5/22/2010
Additional Observations:
Dose #: 3
Doses in Series: 5
Valid Dose: Y
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: D409QS3255
Exp Date: 12/1/2010
Manufacturer: Sanofi Pasteur Inc (MVX PMC)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Thigh (HL7 LT)
Vaccine Group: diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
Administered: diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106)
DAPTACEL (NDC 49281-0286-01)"
Date Administered: 2/21/2011
Additional Observations:
Dose #: 4
Doses in Series: 5
Valid Dose: Y
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: D409QS249
Exp Date: 3/1/2011
Manufacturer: Sanofi Pasteur Inc (MVX PMC)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Deltoid (HL7 LD)
Vaccine Group: Hib, unspecified formulation
Administered: Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49)
PedvaxHIB (NDC 00006-4897-00)"
Date Administered: 1/22/2010
Additional Observations:
Dose #: 1
Doses in Series: 4
Valid Dose: Y
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: 7M54K9245
Exp Date: 3/24/2010
Manufacturer: Merck Sharp & Dohme Corp (MVX MSD)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Right Thigh (HL7 RT)
Vaccine Group: Hib, unspecified formulation
Administered: Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49)
PedvaxHIB (NDC 00006-4897-00)"
Date Administered: 3/23/2010
Additional Observations:
Dose #: 2
Doses in Series: 4
Valid Dose: Y
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: 7M55K3342
Exp Date: 10/30/2010
Manufacturer: Merck Sharp & Dohme Corp (MVX MSD)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Thigh (HL7 LT)
Vaccine Group: Hib, unspecified formulation
Administered: Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49)
PedvaxHIB (NDC 00006-4897-00)"
Date Administered: 5/22/2010
Additional Observations:
Dose #: 3
Doses in Series: 4
Valid Dose: Y
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: 7M75K4566
Exp Date: 5/23/2010
Manufacturer: Merck Sharp & Dohme Corp (MVX MSD)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Right Thigh (HL7 RT)
Vaccine Group: Hib, unspecified formulation
Administered: Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49)
PedvaxHIB (NDC 00006-4897-00)"
Date Administered: 2/21/2011
Additional Observations:
Dose #: 4
Doses in Series: 4
Valid Dose: Y
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: 7M53K5534
Exp Date: 2/22/2011
Manufacturer: Merck Sharp & Dohme Corp (MVX MSD)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Deltoid (HL7 LD)
Vaccine Group: poliovirus vaccine, inactivated
Administered: poliovirus vaccine, inactivated (CVX 10)
IPOL (NDC 49281-0860-55)
Date Administered: 1/22/2010
Additional Observations:
Dose #: 1
Doses in Series: 4
Valid Dose: Y
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: D333PV2431
Exp Date: 10/4/2010
Manufacturer: Sanofi Pasteur Inc (MVX PMC)
Route: Subcutaneous (NCIT C38299, HL70162: SC)
Site: Left Deltoid (HL7 LD)
Vaccine Group: poliovirus vaccine, inactivated
Administered: poliovirus vaccine, inactivated (CVX 10)
IPOL (NDC 49281-0860-55)
Date Administered: 3/23/2010
Additional Observations:
Dose #: 2
Doses in Series: 4
Valid Dose: Y
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: D333PV4344
Exp Date: 3/23/2010
Manufacturer: Sanofi Pasteur Inc (MVX PMC)
Route: Subcutaneous (NCIT C38299, HL70162: SC)
Site: Left Deltoid (HL7 LD)
Vaccine Group: pneumococcal, unspecified formulation
Administered: pneumococcal conjugate vaccine, 13 valent (CVX 133)
PREVNAR 13 (NDC 00005-1971-05)"
Date Administered: 1/22/2010
Additional Observations:
Dose #: 1
Doses in Series: 4
Valid Dose: Y
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: P243V3281
Exp Date: 1/30/2010
Manufacturer: Pfizer, Inc (MVX PFR)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Thigh (HL7 LT)
Vaccine Group: pneumococcal, unspecified formulation
Administered: pneumococcal conjugate vaccine, 13 valent (CVX 133)
PREVNAR 13 (NDC 00005-1971-05)"
Date Administered: 3/23/2010
Additional Observations:
Dose #: 2
Doses in Series: 4
Valid Dose: Y
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: P343V8321
Exp Date: 3/30/2010
Manufacturer: Pfizer, Inc (MVX PFR)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Thigh (HL7 LT)
Vaccine Group: pneumococcal, unspecified formulation
Administered: pneumococcal conjugate vaccine, 13 valent (CVX 133)
PREVNAR 13 (NDC 00005-1971-05)"
Date Administered: 5/22/2010
Additional Observations:
Dose #: 3
Doses in Series: 4
Valid Dose: Y
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: P853V2164
Exp Date: 8/30/2010
Manufacturer: Pfizer, Inc (MVX PFR)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Right Thigh (HL7 RT)
Vaccine Group: pneumococcal, unspecified formulation
Administered: pneumococcal conjugate vaccine, 13 valent (CVX 133)
PREVNAR 13 (NDC 00005-1971-05)"
Date Administered: 2/21/2011
Additional Observations:
Dose #: 4
Doses in Series: 4
Valid Dose: Y
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: P853V58532
Exp Date: 4/18/2011
Manufacturer: Pfizer, Inc (MVX PFR)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Deltoid (HL7 LD)
Vaccine Group: rotavirus, unspecified formulation
Administered: rotavirus, live, monovalent vaccine (CVX 119)
ROTARIX (NDC 58160-0854-52)"
Date Administered: 1/22/2010
Additional Observations:
Dose #: 1
Doses in Series: 3
Valid Dose: Y
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: 1 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: 6359RV533
Exp Date: 2/15/2010
Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Thigh (HL7 LT)
Vaccine Group: rotavirus, unspecified formulation
Administered: rotavirus, live, monovalent vaccine (CVX 119)
ROTARIX (NDC 58160-0854-52)"
Date Administered: 3/23/2010
Additional Observations:
Dose #: 2
Doses in Series: 3
Valid Dose: Y
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: 1 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: 6359RV932
Exp Date: 5/10/2011
Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Right Thigh (HL7 RT)
Vaccine Group: influenza, unspecified formulation
Administered: Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161)
FLUZONE QUADRIVALENT (NDC 49281-0514-25)"
Date Administered: 9/25/2010
Additional Observations:
Dose #: 1
Doses in Series: 2
Valid Dose: Y
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .25 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: D8043IN8734
Exp Date: 3/12/2011
Manufacturer: Sanofi Pasteur Inc (MVX PMC)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Thigh (HL7 LT)
Vaccine Group: influenza, unspecified formulation
Administered: Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161)
FLUZONE QUADRIVALENT (NDC 49281-0514-25)"
Date Administered: 10/27/2010
Additional Observations:
Dose #: 2
Doses in Series: 2
Valid Dose: Y
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .25 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: D8043IN8734
Exp Date: 3/12/2011
Manufacturer: Sanofi Pasteur Inc (MVX PMC)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Right Thigh (HL7 RT)
Vaccine Group: influenza, unspecified formulation
Administered: Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161)
FLUZONE QUADRIVALENT (NDC 49281-0514-25)"
Date Administered: 10/2/2011
Additional Observations:
Dose #:
Doses in Series:
Valid Dose:
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .25 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: D9334IN9333
Exp Date: 5/22/2012
Manufacturer: Sanofi Pasteur Inc (MVX PMC)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Deltoid (HL7 LD)
Vaccine Group: influenza, unspecified formulation
Administered: Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161)
FLUZONE QUADRIVALENT (NDC 49281-0514-25)"
Date Administered: 11/4/2012
Additional Observations:
Dose #:
Doses in Series:
Valid Dose:
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .25 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: D9553IN2243
Exp Date: 4/30/2012
Manufacturer: Sanofi Pasteur Inc (MVX PMC)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Deltoid (HL7 LD)
Vaccine Group: influenza, unspecified formulation
Administered: influenza, live, intranasal, quadrivalent (CVX 149)
FluMist Quadrivalent (NDC 66019-0301-10)"
Date Administered: Current Date
Additional Observations:
Dose #:
Doses in Series:
Valid Dose:
Ordering Provider: Sandra Molina
Entered By: Frank Smith
Entering Organization: Oceanview Pediatrics
Administered Amt: .2 mL
Administering Provider: Sandra Molina
Administered at Location: 400 Shoreline Drive, Stamford Connecticut 06901
Lot#: 8L4B3521
Exp Date: 7/15/2015
Manufacturer: MedImmune,LLC (MVX MED)
Route: Nasal (NCIT C38284), Nasal (HL70162 NS)
Site:
Vaccine Group: Hep A, unspecified formulation
Administered: hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule (CVX 83)
HAVRIX (NDC 58160-0825-52)"
Date Administered: 11/23/2011
Additional Observations:
Dose #: 1
Doses in Series: 2
Valid Dose: Y
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: 6359RT33
Exp Date: 1/4/2012
Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Right Deltoid (HL7 RD)
Vaccine Group: Hep A, unspecified formulation
Administered: hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule (CVX 83)
HAVRIX (NDC 58160-0825-52)"
Date Administered: 5/23/2012
Additional Observations:
Dose #: 2
Doses in Series: 2
Valid Dose: Y
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: 6359RT48
Exp Date: 9/11/2012
Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Deltoid (HL7 LD)
Vaccine Group: MMRV
Administered: measles, mumps, rubella, and varicella virus vaccine (CVX 94)
ProQuad (NDC 00006-4999-00)"
Date Administered: 10/23/2010
Additional Observations:
Dose #:
Doses in Series: 2
Valid Dose: N
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: 7W27V7491
Exp Date: 12/15/2010
Manufacturer: Merck Sharp & Dohme Corp (MVX MSD)
Route: Subcutaneous (NCIT C38299, HL70162: SC)
Site: Left Thigh (HL7 LT)
Vaccine Group: MMRV
Administered: measles, mumps, rubella, and varicella virus vaccine (CVX 94)
ProQuad (NDC 00006-4999-00)"
Date Administered: 11/22/2012
Additional Observations:
Dose #: 1
Doses in Series: 2
Valid Dose: Y
Ordering Provider: Carlos Herrera
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 333 Oceanview Lane, Stamford Connecticut 06901
Lot#: 7W87V3452
Exp Date: 4/13/2013
Manufacturer: Merck Sharp & Dohme Corp (MVX MSD)
Route: Subcutaneous (NCIT C38299, HL70162: SC)
Site: Left Deltoid (HL7 LD)
Vaccine Group: MMRV
Administered: measles, mumps, rubella, and varicella virus vaccine (CVX 94)
ProQuad (NDC 00006-4999-00)"
Date Administered: Current Date
Additional Observations: Reaction (LOINC 31044-1)/fever of >40.5C (105F) within 48 hours of dose (CDCPHINVS VXC12)
Dose #: 2
Doses in Series: 2
Valid Dose: Y
Ordering Provider: Sandra Molina
Entered By: Frank Smith
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: Sandra Molina
Administered at Location: 400 Shoreline Drive, Stamford Connecticut 06901
Lot#: 7W87V3687
Exp Date: 7/15/2015
Manufacturer: Merck Sharp & Dohme Corp (MVX MSD)
Route: Subcutaneous (NCIT C38299, HL70162: SC)
Site: Left Deltoid (HL7 LD)
The Following Vaccine Forecast is displayed:
Vaccine Group: IPV
Due Date: 11/22/2013
Earliest Date to Give: 11/22/2013
Latest Date to Give: 11/22/2015
Overdue Date: 11/23/2015
Immunization Schedule: ACIP
Vaccine Group: influenza, unspecified formulation
Due Date: 10/21/2016
Earliest Date to Give: 9/1/2016
Latest Date to Give: 2/29/2017
Overdue Date: 3/1/3027
Immunization Schedule: ACIP
|
| Notes to Testers |
|---|
No Note |
| Description |
|---|
| Following the vaccination visit, the provider uses the EMR to produce an immunization report for the patient including all history (the report can be provided in various formats - e.g., print, send to patient portal, etc.) |
| Comments |
|---|
| No Comments |
| PreCondition |
|---|
| Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR. New vaccinations have been administered. |
| PostCondition |
|---|
| The patient/parent has been provided a patient immunization history report. |
| Test Objectives |
|---|
| Produce Standard Patient Immunization History Report: The EHR or other clinical software system produces a report of a patient's immunization history that is appropriate for various entities, such as schools and day-care centers. |
| Evaluation Criteria |
|---|
| No evaluation criteria |
| Notes to Testers |
|---|
| No Note |
| Description |
|---|
|
Following the vaccination visit, the provider uses the EMR to produce an immunization report for the patient including all history (the report can be provided in various formats - e.g., print, send to patient portal, etc.) |
| Comments |
|---|
No Comments |
| PreCondition |
|---|
|
Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR. New vaccinations have been administered. |
| PostCondition |
|---|
|
The patient/parent has been provided a patient immunization history report. |
| Test Objectives |
|---|
|
Produce Standard Patient Immunization History Report: The EHR or other clinical software system produces a report of a patient's immunization history that is appropriate for various entities, such as schools and day-care centers. |
| Evaluation Criteria |
|---|
The following patient demographics are displayed:
Patient Identifier Number: Vendor Assigned
Patient Identifier Type Code: Vendor Assigned
Patient Name: Juan Marcel Gonzales
Date/Time of Birth: 11/23/2011 11:00am
Sex: Male
Patient Address: 4623 Standish Way, Stamford, CT 06903
Multiple Birth: N
Birth Order: NA
The following Vaccination History is displayed:
Vaccine Group: Hep B Peds NOS
Administered: hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08)
ENGERIX-B (NDC 58160-0820-11)"
Date Administered: 11/23/2011
Additional Observations:
Dose #: 1
Doses in Series: 3
Valid Dose: Y
Ordering Provider: Jane Carter
Entered By: Lisa Sirtis
Entering Organization: Shoreline Hospital
Administered Amt: .05 mL
Administering Provider: Jane Carter
Administered at Location: 325 Shorline Drive,
Stamford Connecticut 06901
Lot#: 6332FK34
Exp Date: 12/14/2011
Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Thigh (HL7 LT)
Vaccine Group: Hep B Peds NOS
Administered: hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08)
ENGERIX-B (NDC 58160-0820-11)"
Date Administered: 12/23/2013
Additional Observations:
Dose #: 2
Doses in Series: 3
Valid Dose: Y
Ordering Provider: J. Rodriguez
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: 6352FK2
Exp Date: 10/1/2011
Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Right Thigh (HL7 RT)
Vaccine Group: Hep B Peds NOS
Administered: hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08)
ENGERIX-B (NDC 58160-0820-11)"
Date Administered: Current Date
Additional Observations:
Dose #: 3
Doses in Series: 3
Valid Dose: Y
Ordering Provider: Sandra Molina
Entered By: Frank Smith
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: Sandra Molina
Administered at Location: 400 Shoreline Drive, Stamford Connecticut 06901
Lot#: 6332FK26
Exp Date: 8/25/2015
Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Deltoid (HL70162 LD)
Vaccine Group: diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
Administered: diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106)
DAPTACEL (NDC 49281-0286-01)"
Date Administered: 1/22/2012
Additional Observations:
Dose #: 1
Doses in Series: 5
Valid Dose: Y
Ordering Provider: J. Rodriguez
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: D409QS2342
Exp Date: 11/30/2012
Manufacturer: Sanofi Pasteur Inc (MVX PMC)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Thigh (HL7 LT)
Vaccine Group: diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
Administered: diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106)
DAPTACEL (NDC 49281-0286-01)"
Date Administered: 3/22/2012
Additional Observations:
Dose #: 2
Doses in Series: 5
Valid Dose: Y
Ordering Provider: J. Rodriguez
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: D409QS2434
Exp Date: 9/4/2012
Manufacturer: Sanofi Pasteur Inc (MVX PMC)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Right Thigh (HL7 RT)
Vaccine Group: diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
Administered: diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106)
DAPTACEL (NDC 49281-0286-01)"
Date Administered: 5/21/2012
Additional Observations:
Dose #: 3
Doses in Series: 5
Valid Dose: Y
Ordering Provider: J. Rodriguez
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: D409QS3256
Exp Date: 12/1/2012
Manufacturer: Sanofi Pasteur Inc (MVX PMC)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Thigh (HL7 LT)
Vaccine Group: diphtheria, tetanus toxoids and acellular pertussis vaccine, unspecified
Administered: diphtheria, tetanus toxoids and acellular pertussis vaccine, 5 pertussis antigens (CVX 106)
DAPTACEL (NDC 49281-0286-01)"
Date Administered: 5/21/2012
Additional Observations:
Dose #: 3
Doses in Series: 5
Valid Dose: Y
Ordering Provider: J. Rodriguez
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: D409QS3256
Exp Date: 12/1/2012
Manufacturer: Sanofi Pasteur Inc (MVX PMC)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Thigh (HL7 LT)
Vaccine Group: Hib, unspecified formulation
Administered: Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49)
PedvaxHIB (NDC 00006-4897-00)"
Date Administered: 1/22/2012
Additional Observations:
Dose #: 1
Doses in Series: 4
Valid Dose: Y
Ordering Provider: J. Rodriguez
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: 7M54K9255
Exp Date: 3/24/2012
Manufacturer: Merck Sharp & Dohme Corp (MVX MSD)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Right Thigh (HL7 RT)
Vaccine Group: Hib, unspecified formulation
Administered: Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49)
PedvaxHIB (NDC 00006-4897-00)"
Date Administered: 3/22/2012
Additional Observations:
Dose #: 2
Doses in Series: 4
Valid Dose: Y
Ordering Provider: J. Rodriguez
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: 7M55K3343
Exp Date: 10/30/2012
Manufacturer: Merck Sharp & Dohme Corp (MVX MSD)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Thigh (HL7 LT)
Vaccine Group: Hib, unspecified formulation
Administered: Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49)
PedvaxHIB (NDC 00006-4897-00)"
Date Administered: 5/21/2012
Additional Observations:
Dose #: 3
Doses in Series: 4
Valid Dose: Y
Ordering Provider: J. Rodriguez
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: 7M75K4577
Exp Date: 5/23/2012
Manufacturer: Merck Sharp & Dohme Corp (MVX MSD)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Right Thigh (HL7 RT)
Vaccine Group: Hib, unspecified formulation
Administered: Haemophilus influenzae type b vaccine, PRP-OMP conjugate (CVX 49)
PedvaxHIB (NDC 00006-4897-00)"
Date Administered: 11/22/2012
Additional Observations:
Dose #: 4
Doses in Series: 4
Valid Dose: Y
Ordering Provider: J. Rodriguez
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: 7M53K5535
Exp Date: 2/22/2012
Manufacturer: Merck Sharp & Dohme Corp (MVX MSD)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Deltoid (HL7 LD)
Vaccine Group: poliovirus vaccine, inactivated
Administered: poliovirus vaccine, inactivated (CVX 10)
IPOL (NDC 49281-0860-55)"
Date Administered: 1/22/2012
Additional Observations:
Dose #: 1
Doses in Series: 4
Valid Dose: Y
Ordering Provider: J. Rodriguez
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: D333PV2444
Exp Date: 10/4/2012
Manufacturer: Sanofi Pasteur Inc (MVX PMC)
Route: Subcutaneous (NCIT C38299, HL70162: SC)
Site: Left Deltoid (HL7 LD)
Vaccine Group: poliovirus vaccine, inactivated
Administered: poliovirus vaccine, inactivated (CVX 10)
IPOL (NDC 49281-0860-55)"
Date Administered: 3/22/2012
Additional Observations:
Dose #: 2
Doses in Series: 4
Valid Dose: Y
Ordering Provider: J. Rodriguez
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: D333PV4343
Exp Date: 3/23/2012
Manufacturer: Sanofi Pasteur Inc (MVX PMC)
Route: Subcutaneous (NCIT C38299, HL70162: SC)
Site: Left Deltoid (HL7 LD)
Vaccine Group: poliovirus vaccine, inactivated
Administered: poliovirus vaccine, inactivated (CVX 10)
IPOL (NDC 49281-0860-55)
Date Administered: 5/21/2012
Additional Observations:
Dose #: 2
Doses in Series: 4
Valid Dose: Y
Ordering Provider: J. Rodriguez
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: D335PV9654
Exp Date: 2/22/2013
Manufacturer: Sanofi Pasteur Inc (MVX PMC)
Route: Subcutaneous (NCIT C38299, HL70162: SC)
Site: Left Deltoid (HL7 LD)
Vaccine Group: pneumococcal, unspecified formulation
Administered: pneumococcal conjugate vaccine, 13 valent (CVX 133)
PREVNAR 13 (NDC 00005-1971-05)"
Date Administered: 1/22/2012
Additional Observations:
Dose #: 1
Doses in Series: 4
Valid Dose: Y
Ordering Provider: J. Rodriguez
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: P243V3321
Exp Date: 1/30/2012
Manufacturer: Pfizer, Inc (MVX PFR)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Thigh (HL7 LT)
Vaccine Group: pneumococcal, unspecified formulation
Administered: pneumococcal conjugate vaccine, 13 valent (CVX 133)
PREVNAR 13 (NDC 00005-1971-05)"
Date Administered: 3/22/2012
Additional Observations:
Dose #: 2
Doses in Series: 4
Valid Dose: Y
Ordering Provider: J. Rodriguez
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: P343V8445
Exp Date: 3/30/2012
Manufacturer: Pfizer, Inc (MVX PFR)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Thigh (HL7 LT)
Vaccine Group: pneumococcal, unspecified formulation
Administered: pneumococcal conjugate vaccine, 13 valent (CVX 133)
PREVNAR 13 (NDC 00005-1971-05)"
Date Administered: 5/21/2012
Additional Observations:
Dose #: 3
Doses in Series: 4
Valid Dose: Y
Ordering Provider: J. Rodriguez
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: P853V2175
Exp Date: 8/30/2012
Manufacturer: Pfizer, Inc (MVX PFR)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Right Thigh (HL7 RT)
Vaccine Group: pneumococcal, unspecified formulation
Administered: pneumococcal conjugate vaccine, 13 valent (CVX 133)
PREVNAR 13 (NDC 00005-1971-05)"
Date Administered: 11/22/2012
Additional Observations:
Dose #: 4
Doses in Series: 4
Valid Dose: Y
Ordering Provider: J. Rodriguez
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: P853V58544
Exp Date: 4/18/2013
Manufacturer: Pfizer, Inc (MVX PFR)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Deltoid (HL7 LD)
Vaccine Group: rotavirus, unspecified formulation
Administered: rotavirus, live, monovalent vaccine (CVX 119)
ROTARIX (NDC 58160-0854-52)"
Date Administered: 1/22/2012
Additional Observations:
Dose #: 1
Doses in Series: 3
Valid Dose: Y
Ordering Provider: J. Rodriguez
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: 1 mL
Administering Provider: J. Martinez
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: 6359RV533
Exp Date: 2/15/2010
Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Thigh (HL7 LT)
Vaccine Group: rotavirus, unspecified formulation
Administered: rotavirus, live, monovalent vaccine (CVX 119)
ROTARIX (NDC 58160-0854-52)"
Date Administered: 3/22/2012
Additional Observations:
Dose #: 2
Doses in Series: 3
Valid Dose: Y
Ordering Provider: J. Rodriguez
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: 1 mL
Administering Provider: J. Martinez
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: 6359RV932
Exp Date: 5/10/2011
Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Right Thigh (HL7 RT)
Vaccine Group: influenza, unspecified formulation
Administered: Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161)
FLUZONE QUADRIVALENT (NDC 49281-0514-25)"
Date Administered: 9/22/2012
Additional Observations:
Dose #: 1
Doses in Series: 2
Valid Dose: Y
Ordering Provider: J. Rodriguez
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .25 mL
Administering Provider: J. Martinez
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: D8043IN8734
Exp Date: 3/12/2013
Manufacturer: Sanofi Pasteur Inc (MVX PMC)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Thigh (HL7 LT)
Vaccine Group: influenza, unspecified formulation
Administered: Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161)
FLUZONE QUADRIVALENT (NDC 49281-0514-25)"
Date Administered: 10/20/2012
Additional Observations:
Dose #: 2
Doses in Series: 2
Valid Dose: Y
Ordering Provider: J. Rodriguez
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .25 mL
Administering Provider: J. Martinez
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: D8043IN8798
Exp Date: 3/12/2013
Manufacturer: Sanofi Pasteur Inc (MVX PMC)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Right Thigh (HL7 RT)
Vaccine Group: influenza, unspecified formulation
Administered: Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161)
FLUZONE QUADRIVALENT (NDC 49281-0514-25)"
Date Administered: 10/30/2013
Additional Observations:
Dose #:
Doses in Series:
Valid Dose:
Ordering Provider: J. Rodriguez
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .25 mL
Administering Provider: J. Martinez
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: D8043IN8734
Exp Date: 5/22/2014
Manufacturer: Sanofi Pasteur Inc (MVX PMC)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Deltoid (HL7 LD)
Vaccine Group: influenza, unspecified formulation
Administered: Influenza, injectable,quadrivalent, preservative free, pediatric (CVX 161)
FLUZONE QUADRIVALENT (NDC 49281-0514-25)"
Date Administered: Current Date
Additional Observations:
Dose #:
Doses in Series:
Valid Dose:
Ordering Provider: Sandra Molina
Entered By: Frank Smith
Entering Organization: Oceanview Pediatrics
Administered Amt: .25 mL
Administering Provider: Sandra Molina
Administered at Location: 400 Shoreline Drive, Stamford Connecticut 06901
Lot#: D8043IN8855
Exp Date: 7/28/2015
Manufacturer: Sanofi Pasteur Inc (MVX PMC)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Thigh (HL7 LT)
Vaccine Group: Hep A, unspecified formulation
Administered: hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule (CVX 83)
HAVRIX (NDC 58160-0825-52)"
Date Administered: 5/21/2013
Additional Observations:
Dose #: 1
Doses in Series: 2
Valid Dose: Y
Ordering Provider: J. Rodriguez
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: 6359RT35
Exp Date: 1/4/2014
Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Right Deltoid (HL7 RD)
Vaccine Group: Hep A, unspecified formulation
Administered: hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule (CVX 83)
HAVRIX (NDC 58160-0825-52)"
Date Administered: 12/1/2013
Additional Observations:
Dose #: 2
Doses in Series: 2
Valid Dose: Y
Ordering Provider: J. Rodriguez
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: 6359RT47
Exp Date: 9/11/2013
Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Deltoid (HL7 LD)
Vaccine Group: MMRV
Administered: measles, mumps, rubella, and varicella virus vaccine (CVX 94)
ProQuad (NDC 00006-4999-00)"
Date Administered: 11/22/2012
Additional Observations:
Dose #: 1
Doses in Series: 2
Valid Dose: Y
Ordering Provider: J. Rodriguez
Entered By: J. Martinez
Entering Organization: Oceanview Pediatrics
Administered Amt: .05 mL
Administering Provider: J. Martinez
Administered at Location: 4253 Standish Way, Stamford Connecticut 06903
Lot#: 7W27V7632
Exp Date: 12/15/2016
Manufacturer: Merck Sharp & Dohme Corp (MVX MSD)
Route: Subcutaneous (NCIT C38299, HL70162: SC)
Site: Left Thigh (HL7 LT)
The Following Vaccine Forecast is displayed:
Vaccine Group: Dtap
Due Date: 11/22/2015
Earliest Date to Give: 11/22/2015
Latest Date to Give: 11/21/2017
Overdue Date: 11/22/2017
Immunization Schedule: ACIP
Vaccine Group: IPV
Due Date: 11/22/2015
Earliest Date to Give: 11/22/2015
Latest Date to Give: 11/21/2017
Overdue Date: 11/22/2017
Immunization Schedule: ACIP
Vaccine Group: Influenza
Due Date: 10/22/2015
Earliest Date to Give: 9/1/2015
Latest Date to Give: 1/31/2016
Overdue Date: 2/1/2016
Immunization Schedule: ACIP
Vaccine Group: MMR
Due Date: 11/22/2015
Earliest Date to Give: 11/22/2015
Latest Date to Give: 11/21/2017
Overdue Date: 11/22/2017
Immunization Schedule: ACIP
Vaccine Group: Varicella
Due Date: 11/22/2015
Earliest Date to Give: 11/22/2015
Latest Date to Give: 11/21/2017
Overdue Date: 11/22/2017
Immunization Schedule: ACIP
|
| Notes to Testers |
|---|
No Note |
| Description |
|---|
| Following the vaccination visit, the provider uses the EMR to produce an immunization report for the patient including all history (the report can be provided in various formats - e.g., print, send to patient portal, etc.) |
| Comments |
|---|
| No Comments |
| PreCondition |
|---|
| Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR. New vaccinations have been administered. |
| PostCondition |
|---|
| The patient/parent has been provided a patient immunization history report. |
| Test Objectives |
|---|
| Produce Standard Patient Immunization History Report: The EHR or other clinical software system produces a report of a patient's immunization history that is appropriate for various entities, such as schools and day-care centers. |
| Evaluation Criteria |
|---|
| No evaluation criteria |
| Notes to Testers |
|---|
| No Note |
| Description |
|---|
|
Following the vaccination visit, the provider uses the EMR to produce an immunization report for the patient including all history (the report can be provided in various formats - e.g., print, send to patient portal, etc.) |
| Comments |
|---|
No Comments |
| PreCondition |
|---|
|
Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR. New vaccinations have been administered. |
| PostCondition |
|---|
|
The patient/parent has been provided a patient immunization history report. |
| Test Objectives |
|---|
|
Produce Standard Patient Immunization History Report: The EHR or other clinical software system produces a report of a patient's immunization history that is appropriate for various entities, such as schools and day-care centers. |
| Evaluation Criteria |
|---|
The following patient demographics are displayed:
Patient Identifier Number: Vendor Supplied
Patient Identifier Type Code: Vendor Supplied
Patient Name: Mariela Gonzales Morales
Date/Time of Birth: 03/30/2015 11:00am
Sex: Female
Patient Address: 3321 Standish Way, Stamford, CT 06903
Multiple Birth: Y
Birth Order: 1
The following Vaccination History is displayed:
Vaccine Group: Hep B Peds NOS
Administered: hepatitis B vaccine, pediatric or pediatric/adolescent dosage (CVX 08)
ENGERIX-B (NDC 58160-0820-11)"
Date Administered: 11/23/2011
Additional Observations:
Dose #: 1
Doses in Series: 3
Valid Dose: Y
Ordering Provider: Jane Carter
Entered By: Lisa Sirtis
Entering Organization: Shoreline Hospital
Administered Amt: .05 mL
Administering Provider: Jane Carter
Administered at Location: 325 Shorline Drive,
Stamford Connecticut 06901
Lot#: 6332FK34
Exp Date: 12/14/2011
Manufacturer: GlaxoSmithKline Biologicals SA (MVX SKB)
Route: Intramuscular (NCIT C28161, HL70162: IM)
Site: Left Thigh (HL7 LT)
The Following Vaccine Forecast is displayed:
Vaccine Group: Hep B Peds NOS
Due Date: 6/29/2015
Earliest Date to Give: 6/29/2015
Latest Date to Give: 7/29/2015
Overdue Date: 7/30/2015
Immunization Schedule: ACIP
Vaccine Group: Dtap
Due Date: 7/29/2015
Earliest Date to Give: 29-Jul-15
Latest Date to Give:
Overdue Date:
Immunization Schedule: ACIP
Vaccine Group: Hib
Due Date: 7/29/2015
Earliest Date to Give: 7/29/2015
Latest Date to Give:
Overdue Date:
Immunization Schedule: ACIP
Vaccine Group: IPV
Due Date: 7/29/2015
Earliest Date to Give: 7/29/2015
Latest Date to Give:
Overdue Date:
Immunization Schedule: ACIP
Vaccine Group: Pneumococcal conjugate
Due Date: 7/29/2015
Earliest Date to Give: 7/29/2015
Latest Date to Give:
Overdue Date:
Immunization Schedule: ACIP
Vaccine Group: Rotavirus
Due Date: 7/29/2015
Earliest Date to Give: 7/29/2015
Latest Date to Give:
Overdue Date:
Immunization Schedule: ACIP
Vaccine Group: Influenza
Due Date: Nov 26, 2015 or later
later
Earliest Date to Give: Nov 26, 2015
Latest Date to Give:
Overdue Date:
Immunization Schedule: ACIP
Vaccine Group: HepA
Due Date: 5/29/2016
Earliest Date to Give: 5/29/2016
Latest Date to Give: 5/29/2017
Overdue Date: 5/30/2017
Immunization Schedule: ACIP
Vaccine Group: MMR
Due Date: 5/29/2016
Earliest Date to Give: 5/29/2016
Latest Date to Give: 8/27/2016
Overdue Date: 8/28/2016
Immunization Schedule: ACIP
Vaccine Group: Varicella
Due Date: 5/29/2016
Earliest Date to Give: 5/29/2016
Latest Date to Give: 8/27/2016
Overdue Date: 8/28/2016
Immunization Schedule: ACIP
|
| Notes to Testers |
|---|
No Note |
| Description |
|---|
The provider periodically uses the EMR to identify the cohort of patients that are overdue for immunizations along with their contact information in order to send reminder notifications to the patients/parents. |
| Comments |
|---|
No Comments |
| PreCondition |
|---|
Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR. The vaccine forecast is available to the EMR. |
| PostCondition |
|---|
The Cohort report for all patients that are overdue for immunizations is available to the provider through the EMR. |
| Test Objectives |
|---|
Produce Population-Level Report: The EHR or other clinical system generates aggregate, population-level reports based on known patient immunization data. |
| Evaluation Criteria | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
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The following patient information is provided on the cohort report:
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| Notes to Testers |
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No Note |
| Description |
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The provider periodically uses the EMR to identify the cohort of patients that are overdue for immunizations along with their contact information in order to send reminder notifications to the patients/parents.
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| Comments |
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No Comments |
| PreCondition |
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Initial Data Load completed with demographic data, vaccination history, and clinical history. Historical Vaccination reconciled and loaded into the EMR. The vaccine forecast is available to the EMR.
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| PostCondition |
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The Cohort report for all patients that are overdue for immunizations is available to the provider through the EMR. |
| Test Objectives |
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Produce Population-Level Report: The EHR or other clinical system generates aggregate, population-level reports based on known patient immunization data. |
| Evaluation Criteria | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
The following patient information is provided on the cohort report:
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| Notes to Testers |
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No Note |